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Arch Ophthalmol. 2003;121:129-130.

We report a rare retinal complication in a premature infant undergoing diode laser treatment for retinopathy of prematurity (ROP).

Report of a Case
A male infant (triplet 2) was born at 27 weeks' postconceptional age at a birth weight of 810 g. Retinopathy of prematurity was present when he was screened at 31 weeks' postconceptional age. Threshold ROP was reached at 33 weeks (8-9 cumulative clock hours of stage 3 ROP in zone 2 with plus disease in 4 quadrants bilaterally). Both eyes were treated with an indirect diode laser (810 nm) via a 28-diopter lens anterior to the ridge (500-mW intensity/500-millisecond duration; 1170 burns OD and 940 burns OS). No adverse cardiovascular or other events were noted during or after treatment.

Immediately following treatment, the posterior poles of both eyes became edematous and elevated. These serous retinal detachments resolved within 3 weeks with no recurrence after 18 months of follow-up. A small pigmented spot developed at both maculae as the edema resolved (Figure 1). The ROP regressed without further treatment.

View larger version (38K): [in this window] [in a new window] A RetCam 120 (Massie Research Laboratories, Inc, Dublin, Calif) photograph of the right fundus of triplet 2 taken 6 weeks after treatment shows laser burns and macular pigmentary change. The macular edema observed clinically is not visible photographically.

Triplet 1 (male; 850-g birth weight) reached threshold ROP at 35 weeks (8-9 cumulative clock hours of stage 3 ROP in zone 2 with plus disease in 4 quadrants bilaterally). Both eyes received indirect diode laser treatment (400-mW intensity/400-millisecond duration; 1200 burns OD and 840 burns OS). No retinal problems were noted following treatment. This infant also developed grade 4 intraventricular hemorrhage. Triplet 3 (female; 990-g birth weight) developed ROP bilaterally but did not reach threshold. All 3 infants received supplemental oxygen.

All infants undergoing ROP screening and treatment undergo dilation with a combination of 0.5% cyclopentolate hydrochloride and 0.5% hydrochloride and 2.5% phenylephrine drops (repeated once). When diode laser treatment is indicated, children are sedated with intravenous morphine.

Comment
Bilateral serous retinal detachment with pigmentary macular change following diode laser treatment for ROP has not been previously reported. Noonan and Clark¹ reported a case of unilateral serous retinal detachment following unilateral argon laser photocoagulation treatment for threshold ROP. Berman and Deutsch² reported a case of bilateral pigment epithelial detachments in a premature neonate being screened for ROP. In both cases, these retinal changes resolved spontaneously without sequelae, and the authors postulated that phenylephrine-induced hemodynamic changes in the choriocapillaris may have been responsible.^1-2 Macular pigmentary changes have been reported following cryotherapy for ROP.³ Williams and Trese⁴ reported a unilateral punched-out macular lesion with pigmentary change in an 11-year-old girl who had been born prematurely but had never received any treatment for ROP.

Phenylephrine drops are an unlikely cause for these posterior segment changes, given their widespread use in preterm infants and the rarity of these complications. We hypothesize that the diode laser treatment in our case may have caused an inflammatory reaction that led to fluid exudation. Fluid collection at the macula may be responsible for subsequently observed macular pigmentary changes, as suggested by Williams and Trese.⁴ However, inflammation following treatment would not explain the retinal changes in children who did not receive treatment^{2, 4}; Different etiological mechanisms may apply in different situations. Individual factors such as very low birth weight, early development and treatment of threshold ROP, and possibly multiple-gestation pregnancy may play a role in the development of subretinal fluid collections in premature infants with ROP.

Alan Mulvihill, FRCSI; Bernadette Lanigan, RGN; Michael O'Keefe, FRCS
Dublin, Ireland

Corresponding author and reprints: Michael O'Keefe, FRCS, National Children's Eye Centre, Children's University Hospital, Temple St, Dublin 1, Ireland (e-mail: mokeefe{at}materprivate.ie).

REFERENCES
1. Noonan CP, Clark DI. Acute serous detachment with argon laser photocoagulation in retinopathy of prematurity. J AAPOS. 1997;1:183-184. 2. Berman DH, Deutsch JA. Bilateral spontaneous pigment epithelial detachments in a premature neonate. Arch Ophthalmol. 1994;112:161-164. ISI | PUBMED 3. Saito Y, Hatsukawa Y, Lewis JM, Koike H, Omoto T, Tano Y. Macular coloboma-like lesions and pigment abnormalities as complications of cryotherapy of retinopathy of prematurity in very low birth-weight infants. Am J Ophthalmol. 1996;122:299-308. ISI | PUBMED 4. Williams JG, Trese MT. A macular lesion simulating an aberrant cryotherapy lesion in retinopathy of prematurity. Arch Ophthalmol. 2000;118:438-439. FREE FULL TEXT

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